Any experiences with 96101-96103 // 90785??

[usopen]

Does anybody have any experience billing for 96101-96103 and 90785 in a private practice setting?

I have couple of questions.

1. Do private insurers reimburse for these?

2. Do you need diagnostic ICD-10 codes associated with those CPT codes?

Any input would be appreciated!

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[splik]

1. yes, however they may require prior authorization and evidence of medical necessity
2. yes, always need ICD-10 codes (typically this will be a dementia, neurodevelopmental, or somatoform code)

although physicians can use 96101-96103 in practice these codes are meant for psychologists doing testing. It is highly unlikely that a psychiatrist in private practice would be doing an MMPI-2, PAI, WAIS, Rorschach etc or other tests that fit under these codes in order to bill for them. If your private practice had psychometrists and psychologists then of course you can bill for these. 90785 is just an interactive complexity code, you add it on to a psychotherapy code on a 90792. You can only use it for the following situations:

1. The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care.
2. Caregiver emotions/behavior that interfere with implementation of the treatment plan.
3. Evidence/disclosure of a sentinel event and man dated report to a third party (e.g., abuse or neglect with report to state agency) with
initiation of discussion of the sentinel event and/or report with patient and other visit participants.
4.Use of play equipment, physical devices, interpreter or translator to overcome significant language barriers.

Last I checked, medicare only reimbursed $8 for 90785 and private insurance a little more, so while you should use it when appropriate, it's not really much of a game changer

 

[usopen]

1. yes, however they may require prior authorization and evidence of medical necessity
2. yes, always need ICD-10 codes (typically this will be a dementia, neurodevelopmental, or somatoform code)

although physicians can use 96101-96103 in practice these codes are meant for psychologists doing testing. It is highly unlikely that a psychiatrist in private practice would be doing an MMPI-2, PAI, WAIS, Rorschach etc or other tests that fit under these codes in order to bill for them. If your private practice had psychometrists and psychologists then of course you can bill for these. 90785 is just an interactive complexity code, you add it on to a psychotherapy code on a 90792. You can only use it for the following situations:

1. The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care.
2. Caregiver emotions/behavior that interfere with implementation of the treatment plan.
3. Evidence/disclosure of a sentinel event and man dated report to a third party (e.g., abuse or neglect with report to state agency) with
initiation of discussion of the sentinel event and/or report with patient and other visit participants.
4.Use of play equipment, physical devices, interpreter or translator to overcome significant language barriers.

Last I checked, medicare only reimbursed $8 for 90785 and private insurance a little more, so while you should use it when appropriate, it's not really much of a game changer

Very informative and helpful! Thank you!

 

[nexus73]

1. yes, however they may require prior authorization and evidence of medical necessity
2. yes, always need ICD-10 codes (typically this will be a dementia, neurodevelopmental, or somatoform code)

although physicians can use 96101-96103 in practice these codes are meant for psychologists doing testing. It is highly unlikely that a psychiatrist in private practice would be doing an MMPI-2, PAI, WAIS, Rorschach etc or other tests that fit under these codes in order to bill for them. If your private practice had psychometrists and psychologists then of course you can bill for these. 90785 is just an interactive complexity code, you add it on to a psychotherapy code on a 90792. You can only use it for the following situations:

1. The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care.
2. Caregiver emotions/behavior that interfere with implementation of the treatment plan.
3. Evidence/disclosure of a sentinel event and man dated report to a third party (e.g., abuse or neglect with report to state agency) with
initiation of discussion of the sentinel event and/or report with patient and other visit participants.
4.Use of play equipment, physical devices, interpreter or translator to overcome significant language barriers.

Last I checked, medicare only reimbursed $8 for 90785 and private insurance a little more, so while you should use it when appropriate, it's not really much of a game changer

I’m confused about where you said adding 90785 onto psychotherapy for 90792. Can you do therapy and bill for it during a 90792 initial psych eval? And also add 90785 for interactive complexity?

 

[usopen]

sorry that should read for psychotherapy OR a 90792 visit. I.e. you cannot use 90785 with straight E/M codes. the separate issue of whether you can do therapy and bill for it during a 90792 visit - the answer is yes- you can bill an initial therapy visit as 90792 as long as your documentation otherwise meets all the requirements for that.

But my understanding is you cannot bill 90792 with any psychotherapy code (90832-90834, 90836-90840)? I think it makes more sense to code it 99204 (or 99205)+whatever appropriate psychotherapy code. There is more charting requirement for 99204, but 99204 itself pays better than 90792. So definitely makes more sense to do 99204+add on therapy code than 90792. Am I missing something here?

 

[singasongofjoy]

1. yes, however they may require prior authorization and evidence of medical necessity
2. yes, always need ICD-10 codes (typically this will be a dementia, neurodevelopmental, or somatoform code)

although physicians can use 96101-96103 in practice these codes are meant for psychologists doing testing. It is highly unlikely that a psychiatrist in private practice would be doing an MMPI-2, PAI, WAIS, Rorschach etc or other tests that fit under these codes in order to bill for them. If your private practice had psychometrists and psychologists then of course you can bill for these. 90785 is just an interactive complexity code, you add it on to a psychotherapy code on a 90792. You can only use it for the following situations:

1. The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care.
2. Caregiver emotions/behavior that interfere with implementation of the treatment plan.
3. Evidence/disclosure of a sentinel event and man dated report to a third party (e.g., abuse or neglect with report to state agency) with
initiation of discussion of the sentinel event and/or report with patient and other visit participants.
4.Use of play equipment, physical devices, interpreter or translator to overcome significant language barriers.

Last I checked, medicare only reimbursed $8 for 90785 and private insurance a little more, so while you should use it when appropriate, it's not really much of a game changer

Do you know if 90785 can be used only in context of therapy, or can it also be used in diagnostics, eg, when translators are required?